Waste, Fraud and Abuse Prevention
It is the firm policy of AMERIGROUP that its subsidiaries, officers, directors and associates have an affirmative obligation to participate in efforts to detect, mitigate and/or prevent waste, fraud and abuse within the health care system. Participation includes reporting suspected waste, fraud and abuse as described in our attached Policy.
AMERIGROUP maintains anonymous hotlines for the reporting of suspected waste, fraud and abuse. The reporting requirements are outlined in our Compliance Reporting policy. In addition to the anonymous hotlines, the CID maintains a Corporate Investigations email address (corpinvest@amerigroupcorp.com).
Hotline: 757-518-3633 or (extension: 3RISK)
Definitions
Waste results in the expenditure of resources in excess of need. Waste can simply be the result of sloppy,
careless or inefficient billing or treatment. This carelessness results in unnecessary costs being incurred by the
Medicaid system. Unlike fraud, waste does not involve the intent to deceive or misrepresent.
Examples include:
- Unintentional duplicate claim submissions for the same service
- Improper coding that results in unnecessary payments
Fraud is the intentional deception or misrepresentation that an individual or entity makes knowing this could
result in unauthorized benefits to that individual, entity or some other party. Fraud is not committed by
accident or mistake.
Note: Failure to include material information is just as significant as adding false information.
Examples include:
- Billing for services not rendered
- Altering or falsifying documentation
- Paying or receiving a kickback for services
- Purposefully charging a fee for items that carried no cost (e.g., free drug samples)
Abuse is an activity not consistent with generally accepted business, medical or fiscal standard practices. These
incorrect billing practices would not be intentional.
Examples include:
- Billing for services not medically necessary
- Inappropriate or insufficient documentation to support services billed
- Quality of care issues that fail to meet professionally recognized standards
- Services mistakenly billed that should not be paid for by Medicaid
AMERIGROUP Associate Training
All Associates are regularly trained on Waste, Fraud and Abuse to ensure understanding and compliance with the latest regulations and the spirit of the laws.
State Specific Policies